Two days with a broken knife blade in the neck - an interesting case of Horner's syndrome

Abstract

SummaryA 25-year-old man presented to the Emergency department in a rural South African hospital after a left, submental neck stab with a knife. Examination was deemed unremarkable, and the patient was discharged, but re-attended 2 days later complaining of a painful, swollen neck. Further examination identified Horner's syndrome, and further investigation revealed that the blade of the knife had remained in the patient's neck. This was successfully removed in theatre.This case illustrates the importance of careful history, examination and diagnostic imaging in the management of penetrating neck injuries. Horner's syndrome can be easily missed in a busy Emergency department and may indicate life-threatening pathology in the context of neck trauma. The difficulties in assessing and managing this type of injury are discussed. BACKGROUND

Sympathetic trunk repair following penetrating injury to the neck

“…2 Typically, the presence of neurology would be considered one of these signs; however, as our case and others demonstrate, the features of Horner's syndrome are subtle and can be easily missed during the primary survey. 4,6 There are a number of reports describing conservative management of these injuries with variable success. 1,4,5 There are certainly reports of complete resolution of Horner's syndrome without intervention, presumably reflecting sympathetic trunk neuropraxia or axonotmesis.…”

“…7 However, in many cases, the neurological deficit persists, which may reflect transection (neurotmesis) of the sympathetic trunk, as was observed in our case. 5,6,8 Neuropraxia cannot be differentiated from a transected nerve based on clinical or radiological assessment. Based on our experience we advocate exploration with a view to identification and repair in cases of sympathetic trunk transection.…”

How Do I Manage Penetrating Neck Trauma?

“…Penetrating neck trauma (PNT) involves a missile or sharp object penetrating the skin and violating the platysma layer of the neck. This includes gunshot wounds, stab or puncture wounds, and impalement injuries (1)(2)(3). PNT represents approximately 5%-10% of all trauma cases that present to the emergency department (4,5).…”